Updated 22 December 2021
We carried out this announced focussed inspection 17 November 2021 under section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. We planned the inspection to check whether the registered provider was meeting the legal requirements in the Health and Social Care Act 2008 and associated regulations. The inspection was led by a Care Quality Commission, (CQC), inspector who was supported by a specialist dental adviser.
To get to the heart of patients’ experiences of care and treatment, we asked the following three questions:
• Is it safe?
• Is it effective?
• Is it well-led?
These questions form the framework for the areas we look at during the inspection.
Our findings were:
Are services safe?
We found this practice was providing safe care in accordance with the relevant regulations.
Are services effective?
We found this practice was providing effective care in accordance with the relevant regulations.
Are services well-led?
We found this practice was providing well-led care in accordance with the relevant regulations.
Background
Deu Dental Headingley is in the Headingley area of the city of Leeds and provides NHS and private dental care and treatment for adults and children.
The dental team includes three dentists, one dental hygiene therapist, three dental nurses including one trainee dental nurse, one receptionist and a practice manager. The practice has three treatment rooms, one of which is located on the ground floor.
The practice is owned by an individual who is the principal dentist there. They have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated regulations about how the practice is run.
During the inspection we spoke with dentists, dental nurses and the practice manager. We looked at practice policies and procedures and other records about how the service is managed.
The practice is open:
Monday to Friday: 9am to 5:30pm
Our key findings were:
- The practice appeared to be visibly clean and well-maintained.
- The provider had infection control procedures which reflected published guidance. However, improvements should be made to the recording of validation tests on the equipment used within those procedures.
- Staff knew how to deal with emergencies. Appropriate medicines and life-saving equipment were available.
- The provider had systems to help them manage risk to patients and staff.
- The provider had safeguarding processes and staff knew their responsibilities for safeguarding vulnerable adults and children.
- The provider had staff recruitment procedures which reflected current legislation.
- The clinical staff provided patients’ care and treatment in line with current guidelines.
- Staff treated patients with dignity and respect and took care to protect their privacy and personal information.
- Improvements should be made to the monitoring of referrals made to other dental practitioners.
- Staff provided preventive care and supported patients to ensure better oral health.
- The provider had effective leadership and a culture of continuous improvement.
- Staff felt involved and supported and worked as a team.
There were areas where the provider could make improvements. They should:
- Improve the practice’s infection control procedures and protocols taking into account the guidelines issued by the Department of Health in the Health Technical Memorandum 01-05: Decontamination in primary care dental practices, and having regard to The Health and Social Care Act 2008: ‘Code of Practice about the prevention and control of infections and related guidance’. In particular tests on the washer disinfector and autoclave and recording of the results.
- Improve the system to ensure patient referrals to other dental or health care professionals are centrally monitored to ensure they are received in a timely manner and not lost.
- Take action to ensure audits of antimicrobial prescribing are undertaken at regular intervals to improve the quality and safety of the service. The practice should also ensure that, where appropriate, audits have documented learning points and the resulting improvements can be demonstrated. Improvements should be made to the system for auditing infection prevention and control to ensure areas for improvement are identified and actioned.